Adolescent Human Papillomavirus Vaccination Research Articles

Determinants of human papillomavirus vaccination uptake among adolescent girls: A theory-based longitudinal study among Hong Kong Chinese parents.

Human papillomavirus (HPV) vaccination uptake among Chinese adolescent girls remains extremely low. This two-year longitudinal study examined theoretical predictors of adolescent girls' HPV vaccination uptake using an extended Theory of Planned Behaviour (TPB). Between February and November 2014, a random sample of 1996 (response rate 60%) Hong Kong Chinese parents of 12- to 17-year-old HPV unvaccinated girls completed baseline telephone interviews assessing attitudes and intention towards HPV vaccination. Six and 12months later 1255 and 979 parents reported their daughters' HPV vaccination status, respectively. Structural equation modelling tested data fit to an TPB-derived hypothesized model of baseline factors predicting parental decisionmaking for adolescent girls' subsequent HPV vaccination uptake. Overall, at 1-year follow-up, only 9.8% (97/988) of participants' daughters received at least one dose of HPV vaccines. Descriptive norms (β=0.28), perceived greater benefits of HPV vaccination (β=0.17), anticipated affective consequences (β=0.32), and attitude to general optional vaccines (β=0.09) were associated with parental vaccination intention. Barriers to HPV vaccination (β=-0.31), descriptive norms (β=0.17), perceived self-efficacy (β=0.73), and vaccination intention (β=0.11) were associated with vaccination planning. Vaccination intention (β=0.31) and planning (β=0.18) modestly predicted vaccination uptake. The lack of government-organized HPV vaccination programme may result in persistent low HPV vaccination uptake and many young women may remain vulnerable to future cervical cancer risk in Hong Kong.

HPV vaccination of adolescents in a dedicated refugee clinic

Objective: Since 1998, more than 3,000 refugees have relocated to our community. They are ultimately referred to a dedicated clinic with specialized services and a designated group of providers in our academic family medicine practice. This study sought to characterize the human papillomavirus (HPV) vaccination rate of refugee adolescents compared to nonrefugee adolescents in the same practice; the hypothesis was that refugees would have a higher vaccination rate because of the structured nature of their care.

Supporting Human Papillomavirus Vaccination in Adolescents: Perspectives From Commercial and Medicaid Health Plans.

An estimated 79 million Americans are infected with human papillomavirus (HPV). Vaccination can reduce the burden of infection and HPV-associated cancers; yet, vaccination rates remain low. Little is known about why some health plans achieve higher vaccination rates. This study sought to identify strategies used by higher-performing health plans to support HPV vaccination. We used 2013 data from the Healthcare Effectiveness Data and Information Set (HEDIS) Human Papillomavirus Vaccine for Female Adolescents measure to identify high-performing plans. The measure examines the percentage of female adolescent plan members who received 3 doses of HPV vaccine by their 13th birthday. High performers were defined as the subset of commercial plans with the top 10 rates and the subset of Medicaid plans with the top 10 rates. An interview guide was developed to assess activities related to providing HPV vaccination. Interviews were conducted with selected plans and audio-recorded. Transcripts were reviewed independently by 2 interviewers and analyzed by hand to identify key themes. Staff members representing 10 plans agreed to be interviewed, representing a diversity of plan size (range, 5500 to >2.7 million members); plan type (about half were commercial, half were Medicaid plans); patient population, from predominantly white to predominantly nonwhite; and geographic region. Plans Participants highlighted multiple strategies that support HPV vaccination, particularly the "normalizing" of the vaccine. Plans' efforts highlighted patient and provider education, reminders, feedback loops, community collaborations, immunization registries, and use of medical home concepts-including team-driven efforts and coordination. There is an important need to improve the uptake of HPV vaccination. As health coverage expands to more organizations and individuals, it will be critical for health plans to consider the strategies implemented by higher-performing organizations. Although HPV immunization rates are low nationally, health plans can employ multiple efforts to encourage vaccination by implementing activities that involve the patient, the provider, and the community.

Adolescent Participation in HPV Vaccine Clinical Trials: Are Parents Willing?

Approximately one-quarter of human papillomavirus (HPV) infections are acquired by adolescents, with a higher burden among racial/ethnic minorities. However, racial/ethnic minorities have been underrepresented in previous HPV vaccine trials. Ongoing and future HPV vaccine optimization trials would benefit from racially- and ethnically-diverse sample of adolescent trial participants. This study examined factors influencing parental willingness to consent to their adolescents’ participation in HPV vaccine clinical trials and tested for possible racial differences. A convenience sample of parents of adolescents (N = 256) completed a cross-sectional survey. Chi square analyses were used to assess racial differences in parental HPV vaccine awareness and intentions and willingness to consent to their child participating in an HPV vaccine clinical trial. Ordinal logistic regression was used to identify factors associated with willingness. Approximately 47% of parents were willing to allow their adolescent to participate in HPV vaccine clinical trials (30.7% African American and 48.3% Caucasian, p = .081). African Americans had lower HPV vaccine awareness (p = .006) but not lower intentions to vaccinate (p = .086). Parental willingness was positively associated with the following variables: Child’s age (p < .039), Perceived Advantages of HPV Vaccination for Adolescents (p = .002), Parental Trust in Medical Researchers (p < .001), and Level of Ease in Understanding Clinical Trial Information (p = .010). Educating parents about the advantages of HPV vaccines for younger adolescents using low-literacy educational materials and building trust between parents and researchers may increase parental willingness to consent to adolescent participation in HPV vaccine clinical trials.

Translating self-persuasion into an adolescent HPV vaccine promotion intervention for parents attending safety-net clinics

ObjectiveSelf-persuasion is an effective behavior change strategy, but has not been translated for low-income, less educated, uninsured populations attending safety-net clinics or to promote human papillomavirus (HPV) vaccination. We developed a tablet-based application (in English and Spanish) to elicit parental self-persuasion for adolescent HPV vaccination and evaluated its feasibility in a safety-net population. MethodsParents (N=45) of age-eligible adolescents used the self-persuasion application. Then, during cognitive interviews, staff gathered quantitative and qualitative feedback on the self-persuasion tasks including parental decision stage. ResultsThe self-persuasion tasks were rated as easy to complete and helpful. We identified six question prompts rated as uniformly helpful, not difficult to answer, and generated non-redundant responses from participants. Among the 33 parents with unvaccinated adolescents, 27 (81.8%) reported deciding to get their adolescent vaccinated after completing the self-persuasion tasks. ConclusionsThe self-persuasion application was feasible and resulted in a change in parents’ decision stage. Future studies can now test the efficacy of the tablet-based application on HPV vaccination. Practice implicationsThe self-persuasion application facilitates verbalization of reasons for HPV vaccination in low literacy, safety-net settings. This self-administered application has the potential to be more easily incorporated into clinical practice than other patient education approaches.

Improving adolescent HPV vaccination in a randomized controlled cluster trial using the 4 Pillars™ practice Transformation Program

ObjectiveUptake of meningococcal vaccine (MCV) and tetanus, diphtheria and pertussis (Tdap) vaccine among adolescents has approached Healthy People 2020 goals, but human papillomavirus (HPV) vaccination has not. This study evaluated an intervention using the 4 Pillars™ Practice Transformation Program to increase HPV, MCV and Tdap uptake among adolescents in primary care practices. MethodsPractices with at least 50 patients 11–17years old with estimated vaccination rates less than national goals, were assigned to intervention (n=11) and control (n=11) groups in a randomized controlled cluster trial; 9 intervention and 11 control sites completed the study. The baseline and active study periods were 7/1/2013–6/30/2014 and 7/1/2014–3/31/2015, respectively. Vaccination and demographic data for patients who had a visit in both study periods were derived from de-identified EMR extractions. Primary outcomes were vaccination rates and percentage point (PP) changes. Data were analyzed in 2015–16. ResultsAmong the cohort of 10,861 adolescent patients, 38% were 11–13years old; 50% were female; 18% were non-white; and 64% were commercially insured. Average baseline HPV initiation rates were 52.5% for intervention and 61.8% for control groups. After 9months, the intervention sites increased HPV initiation 10.2PP compared with 7.3PP in control sites (P<0.001); HPV series completion rates did not differ between groups. Implementation of >10 strategies to improve rates significantly increased the likelihood of HPV series initiation (OR=2.06, 95% CI=1.43, 2.96). ConclusionsUsing >10 strategies from the 4 Pillars™ Practice Transformation Program is effective for increasing HPV series initiation among adolescents.Clinical trial registry number: NCT02165722.

Measuring Adolescent Human Papillomavirus Vaccine Coverage: A Match of Sexually Transmitted Disease Clinic and Immunization Registry Data

PurposeHuman papillomavirus (HPV) vaccine is recommended for adolescents. By the end of 2013, 64% of female and 40% of male New York City residents aged 13–18 years had received ≥1 HPV vaccine dose. Adolescents attending sexually transmitted disease (STD) clinics are at high risk for HPV exposure and could benefit from vaccination. Our objective was to estimate HPV vaccination coverage for this population. MethodsWe matched records of New York City's STD clinic patients aged 13–18 years during 2010–2013 with the Citywide Immunization Registry. We assessed HPV vaccine initiation (≥1 dose) and series completion (≥3 doses among those who initiated) as of clinic visit date and by patient demographics. We compared receipt of ≥1 dose for HPV, tetanus-diphtheria-acellular pertussis, and meningococcal conjugate vaccine. ResultsEighty-two percent of clinic attendees (13,505/16,364) had records in the Citywide Immunization Registry. Receipt of ≥1 HPV dose increased during 2010–2013 (females: 57.6%–69.7%; males: 1.5%–36.3%). Among females, ≥1-dose coverage was lowest among whites (53.4%) and highest among Hispanics (73.3%); among males, ≥1-dose coverage was lowest among whites (6.9%) and highest among Asians (20.9%). Series completion averaged 57.7% (females) and 28.0% (males), with little variation by race/ethnicity or poverty level. Receipt of ≥1 dose was 59.7% for HPV, 82% for tetanus-diphtheria-acellular pertussis, and 76% for meningococcal conjugate vaccines. ConclusionsHPV vaccine initiation and completion were low among adolescent STD clinic patients; coverage was lower compared with other recommended vaccines. STD clinics may be good venues for delivering HPV vaccine, thereby enhancing efforts to improve HPV vaccination.

Cervical cytological abnormalities and human papilloma virus infection in women infected with HIV in Southern India.

The aim of this study was to examine the association between CD4 count, human papilloma virus (HPV) infection, and the risk of cervical intraepithelial neoplasia among HIV-infected women. A cross-sectional study was conducted among 104 HIV-infected women attending an antiretroviral therapy clinic. They underwent Pap smear and cervical HPV DNA testing. The overall prevalence of HPV infection was 57.7%. HPV 16 was the commonest genotype found (38.5%); HPV 16 and 18 put together contributed to 73.3% of HPV infection; 27.5% of HIV-infected women had squamous cell abnormalities. Cervical intraepithelial neoplasia was less likely among women with CD4 count>500/mm3 (12%) and in those without opportunistic infections (17.8%). The prevalence of high-risk HPV infection was higher in women with high-grade squamous intraepithelial lesions or greater lesions (85.7%) as compared to women with normal cytology (52.1%). The high prevalence of HPV infection and cervical intraepithelial neoplasia in HIV-infected women warrants the need for regular Pap smear screening in these women and routine HPV vaccination for adolescents to reduce the burden of cervical cancer in India.

Clinician and Parent Perspectives on Educational Needs for Increasing Adolescent HPV Vaccination.

Human papillomavirus (HPV)-related morbidity and mortality remain a significant public health burden despite the availability of HPV vaccines for cancer prevention. We engaged clinicians and parents to identify barriers and opportunities related to adolescent HPV vaccination within a focused geographic region. This mixed-method study design used an interviewer-administered semi-structured interview with clinicians (n=52) and a written self-administered survey with similar items completed by parents (n=54). Items focused on experiences, opinions, and ideas about HPV vaccine utilization in the clinical setting, family, and patient perceptions about HPV vaccination and potential future efforts to increase vaccine utilization. Quantitative items were analyzed using descriptive statistics, while qualitative content was analyzed thematically. Suggested solutions for achieving higher rates of HPV vaccination noted by clinicians included public health education, the removal of stigma associated with vaccines, media endorsements, and targeting parents as the primary focus of educational messages. Parents expressed the need for more information about HPV-related disease, HPV vaccines, vaccine safety, sexual concerns, and countering misinformation on social media. Results from this mixed-method study affirm that educational campaigns targeting both health care professionals and parents represent a key facilitator for promoting HPV vaccination; disease burden and cancer prevention emerged as key themes for this messaging.

Modification and validation of the Treatment Self Regulation Questionnaire to assess parental motivation for HPV vaccination of adolescents

BackgroundAccording to Self-Determination Theory, the extent to which the motivation underlying behavior is self-determined or controlled influences its sustainability. This is particularly relevant for behaviors that must be repeated, such as completion of the human papillomavirus (HPV) vaccine series. To date, no measures of motivation for HPV vaccination have been developed. MethodsAs part of a larger study, parents (N=223) whose adolescents receive care at safety-net clinics completed a telephone questionnaire about HPV and the vaccine. We modified the Treatment Self-Regulation Questionnaire to assess parents’ motivation for HPV vaccination in both Spanish and English. We used confirmatory factor analysis to test a three-factor measurement model. ResultsThe three-factor model fit the data well (RMSEA=0.04, CFI=0.98, TLI=0.96), and the scales’ reliabilities were adequate (autonomous: α=0.87; introjected: α=0.72; external: α=0.72). The factor loading strength for one item was stronger for Spanish- than English-speaking participants (p<0.05); all others were equivalent. The intercorrelations among the scales ranged from −0.17 to 0.32, suggesting discriminant factors. The scales displayed the expected pattern of correlations with other psychosocial determinants of behavior. Vaccination intentions showed a strong correlation with autonomous motivation (r=0.52), but no correlation with external motivation (r=0.02), suggesting autonomous motivation may be particularly important in vaccine decision-making. ConclusionFindings support the use of three subscales to measure motivation in HPV vaccination and suggest possible cultural differences in motivation.

Human Papillomavirus Vaccination of Adolescents with Chronic Medical Conditions: A National Survey of Pediatric Subspecialists

Study ObjectiveMany adolescents with chronic medical conditions (CMCs) are at risk of human papillomavirus (HPV) infection, associated complications, and underimmunization and often identify a pediatric subspecialist as their main provider. This study aimed to assess the HPV-related understanding, beliefs, and practices of pediatric subspecialists, which are largely unknown. Design and SettingNational cross-sectional study. ParticipantsPediatric endocrinologists, hematologist/oncologists, pulmonologists, and rheumatologists identified using the American Medical Association Physician Masterfile (n = 418). InterventionsSubspecialists who care for adolescents with CMCs in the outpatient setting were recruited to complete a Web-based survey on their HPV-related knowledge, attitudes, comfort, and practices. Main Outcome MeasuresHPV vaccination recommendation. ResultsOver half of respondents (50.4%; n = 196/389) reported sometimes or always recommending HPV vaccination to adolescent patients with CMCs. Factors positively associated with recommendation included hematology/oncology (adjusted odds ratio [AOR], 4.69; 95% confidence interval [CI], 1.86-11.81) or rheumatology (AOR, 6.55; 95% CI, 1.67-25.74) specialization, seeing more adolescent patients with CMCs (AOR, 1.01; 95% CI, 1.00-1.02), and sometimes or always discussing sexual health (AOR, 2.53; 95% CI, 1.05-6.08) or checking vaccine status (AOR, 3.83; 95% CI, 1.59-9.20) with these patients. Those who thought it was important, but were uncomfortable discussing sexual health when recommending HPV vaccination (AOR, 0.28; 95% CI, 0.12-0.70) or who reported insufficient HPV vaccine information (AOR, 0.45; 95% CI, 0.23-0.88) or lack of primary–subspecialty care provider communication (AOR, 0.38; 95% CI, 0.16-0.93) as barriers to HPV vaccination were less likely to recommend HPV vaccination. ConclusionThis study revealed that many subspecialists fail to recommend HPV vaccination to adolescents with CMCs and highlights potential targets for future interventions.

Are state laws granting pharmacists authority to vaccinate associated with HPV vaccination rates among adolescents?

ObjectivesWe explored whether state laws allowing pharmacists to administer human papillomavirus (HPV) vaccinations to adolescents are associated with a higher likelihood of HPV vaccine uptake. MethodsWe examined provider-reported HPV vaccination among 13–17year olds in the National Immunization Survey-Teen: 2008–2014 for girls (N=48,754) and 2010–2014 for boys (N=31,802). Outcome variables were HPV vaccine initiation (⩾1 dose) and completion (⩾3 doses). The explanatory variable of interest was a categorical variable for the type of pharmacist authority regarding HPV vaccination for adolescents (<18years) in the state: not permitted (reference), by prescription, by collaborative practice protocol, or independent authority. We ran separate difference-in-difference regression models by sex. ResultsDuring 2008–2014, 15 states passed laws allowing pharmacists to administer HPV vaccine to adolescents. Pharmacist authority laws were not statistically significantly associated with increased HPV vaccine initiation or completion. ConclusionsAs currently implemented, state laws allowing pharmacists to administer HPV vaccine to adolescents were not associated with uptake. Possible explanations that need further research include restrictions on pharmacists’ third-party billing ability and the lack of promotion of pharmacy vaccination services to age-eligible adolescents.

Awareness of HPV and Uptake of Vaccination in a High-Risk Population

Immunization against the human papillomavirus (HPV) is effective at preventing HPV-related cancers, but vaccination rates have remained low. Levels of awareness could conceivably influence vaccination rates, but currently the relationship is unknown. This is the first study to test how strongly levels of awareness among parents and adolescents are related to subsequent HPV vaccination among a high-risk population of adolescents. This longitudinal cohort study measured baseline levels of awareness (about HPV, cervical cancer, HPV vaccination, and news or advertisements about HPV vaccination) among parents of adolescents and also a separate sample of adolescents. Participants resided in predominantly low-income, African American neighborhoods of a large American city. During a 12-month follow-up period, the outcome measures were defined as adolescent receipt of any HPV vaccination, as measured by clinic records. Within 1 year, <16% of adolescents received vaccination. The relationship between awareness and subsequent vaccination was either not statistically significant or not meaningful in magnitude, with R(2) = 0.004 to 0.02. The predicted probability of getting vaccination was <0.50 for all awareness levels and prediction accuracy was poor (area under the curve = 0.56-0.64). In this high-risk population, levels of awareness among parents and adolescents were not substantially related to subsequent adolescent HPV vaccination.

Concordance of adolescent human papillomavirus vaccination parental report with provider report in the National Immunization Survey-Teen (2008–2013)

ObjectivesTo examine the accuracy of parental report of HPV vaccination through examination of concordance, with healthcare provider vaccination report as the comparison. MethodsThe 2008–2013 National Immunization Survey (NIS)-Teen was used to examine accuracy of parent reports of HPV vaccination for their female daughters aged 13–17years, as compared with provider report of initiation and number of doses. Multivariable logistic regression models were used to examine associations related to concordance of parent and provider report. ResultsOf 51,746 adolescents, 84% concordance for HPV vaccine initiation and 70% concordance for number of doses was observed. Accuracy varied by race/ethnicity, region, time, and income. The parent report of number of doses was more likely to be accurate among parents of 13 and 14year old females than 17year olds. Accuracy of initiation and number of doses were lower among Hispanic and black adolescents compared to white parents. The odds of over-report was higher among minorities compared to whites, but the odds of underreport was also markedly higher in these groups compared to parents of white teens. Accuracy of parental vaccine report decreased across time. ConclusionsThese findings are important for healthcare providers who need to ascertain the vaccination status of young adults. Strengthening existing immunization registries to improve data sharing capabilities and record completeness could improve vaccination rates, while avoiding costs associated with over-vaccination.

Influence of Sources of Information and Parental Attitudes on Human Papillomavirus Vaccine Uptake among Adolescents

Study ObjectiveThe purpose of this study was to: 1) describe parental sources of information about human papillomavirus (HPV) vaccination for adolescents, 2) understand how parental sources of information about HPV vaccine are associated with adolescent HPV vaccine uptake, and 3) understand if the relationship between a greater number of HPV-related information sources and HPV vaccine uptake among adolescents is mediated by parental attitudes. Design, Setting, Participants, and InterventionsWe conducted a 3-arm randomized controlled trial in middle and high schools in eastern Georgia from 2011 to 2013. As part of the trial, we surveyed parents during the final year to understand their sources of information about HPV vaccine for their adolescent. Data were collected from 360 parents via phone and online surveys. Main Outcome MeasuresParents responded to a survey that asked them to identify demographic information, parental HPV attitudes, sources of information about HPV vaccination, and HPV vaccine uptake. ResultsMost of the sample was African American (74%; n = 267) and 53% of parents (n = 192) reported that their adolescent received at least 1 HPV vaccine dose. The top sources of information about HPV vaccine reported by parents were a doctor or medical professional (80%; n = 287) and television (64%; n = 232). A mediation analysis showed sources of information about HPV vaccine are associated with parental attitudes, and parental attitudes about HPV vaccine are associated with vaccine uptake among adolescents. ConclusionThese findings highlight the importance of HPV sources of information on parental attitudes.

Developing a Tablet-Based Self-Persuasion Intervention Promoting Adolescent HPV Vaccination: Protocol for a Three-Stage Mixed-Methods Study.

BackgroundHuman papillomavirus (HPV)-related cancers are a significant burden on the US health care system that can be prevented through adolescent HPV vaccination. Despite guidelines recommending vaccination, coverage among US adolescents is suboptimal particularly among underserved patients (uninsured, low income, racial, and ethnic minorities) seen in safety-net health care settings. Many parents are ambivalent about the vaccine and delay making a decision or talking with a provider about it. Self-persuasion—generating one’s own arguments for a health behavior—may be particularly effective for parents who are undecided or not motivated to make a vaccine decision.ObjectiveThrough a 3-stage mixed-methods protocol, we will identify an optimal and feasible self-persuasion intervention strategy to promote adolescent HPV vaccination in safety-net clinics.MethodsIn Stage 1, we will define content for a tablet-based self-persuasion app by characterizing (1) parents’ self-generated arguments through cognitive interviews conducted with parents (n=50) of patients and (2) parent-provider HPV vaccine discussions through audio recordings of clinic visits (n=50). In Stage 2, we will compare the effects of the four self-persuasion intervention conditions that vary by cognitive processing level (parents verbalize vs listen to arguments) and choice of argument topics (parents choose vs are assigned topics) on parental vaccine intentions in a 2 × 2 factorial design randomized controlled trial (n=160). This proof-of-concept trial design will identify which intervention condition is optimal by quantitatively examining basic self-persuasion mechanisms (cognitive processing and choice) and qualitatively exploring parent experiences with intervention tasks. In Stage 3, we will conduct a pilot trial (n=90) in the safety-net clinics to assess feasibility of the optimal intervention condition identified in Stage 2. We will also assess its impact on parent-provider discussions.ResultsThis paper describes the study protocol and activities to date. Currently, we have developed the initial prototype of the tablet app for English- and Spanish-speaking populations, and completed Stage 1 data collection.ConclusionsOur systematic collaboration between basic and applied behavioral scientists accelerates translation of promising basic psychological research into innovative interventions suitable for underserved, safety-net populations. At project’s end, we plan to have a feasible and acceptable self-persuasion intervention that can affect key cancer disparities in the United States through prevention of HPV-related cancers.Trial RegistrationClinicalTrials.gov http://clinicaltrials.gov/ct2/show/NCT02537756 and http://clinicaltrials.gov/ct2/show/NCT02535845 (Archived by WebCite at http://www.webcitation.org/6e5XcOGXz and http://www.webcitation.org/6e5XfHoic, respectively).

Adolescent Human Papillomavirus Vaccine Attitudes by Education Level and Factors Associated With Vaccine Completion

Adolescent Human Papillomavirus Vaccine Attitudes by Education Level and Factors Associated With Vaccine Completion

Analysis of trends is insufficient to posit the existence of two aetiological types of cervical cancer.

I've often told students that we understand the aetiology of cervical cancer better than almost any other cancer. As Walboomers and colleagues (J Pathol 1999;189:12–9) concluded: human papillomavirus (HPV) is a necessary cause. It is therefore refreshing to be challenged to question whether there might in fact be two types of cervical cancer with distinct aetiologies (Seppä et al. BJOG 2015; doi: 10.1111/1471-0528.13754). It is accepted that squamous cell carcinoma of the vulva can develop in one of two ways, but that has not seriously been postulated for cervical cancer since the role of HPV was identified in the late 1980s. Nevertheless it is still possible that the cofactors that allow cervical cancer to develop in a young woman soon after HPV infection are distinct from those associated with cancer evolving slowly over several decades. Vulval, like cervical, cancer has an unusual age incidence curve, but it also has two distinct types (Trimble et al. Obstet Gynecol 1996;87:59–64). Cases in younger women tend to be associated with HPV infection (and not p53 mutations); basaloid or warty in appearance; and often develop within a field of vulval intraepithelial neoplasia (VIN). Cancers in older women (over 55 years) only rarely have HPV DNA present. These keratinising cancers are more likely to be associated with lichen sclerosis than with VIN and often have p53 mutations. There are no such differences between cervical cancer in younger and older women. The epidemiological risk factors distinguishing women with cervical HPV infection but no cancer from those with cancer are the same at all ages (e.g. Deacon et al. Br J Cancer 2000;83:1565–72). Nevertheless, we (Sasieni et al. Br J Cancer 2003;89:88–93) and others have shown that cervical cancer in young women is less susceptible to prevention by screening than it is in older women, which supports the idea of cervical cancer being heterogeneous. Analysis of age-specific trends in cervical cancer is complicated by three factors: To account for these effects I would have applied the two-component model to birth-cohorts rather than to periods and explicitly modelled the impact of screening. It is impressive that the model fits the data in Figure 1 of the linked article so well; however, it has five parameters, so it is not altogether surprising that it is rich enough to approximate closely a wide variety of unimodal and bimodal curves. Efforts to control cervical cancer should remain focused on HPV vaccination of adolescents and screening of unvaccinated women aged 25–64. A better understanding of the aetiology of cervical cancer beyond HPV infection is important for cervical cancer control in women who were not vaccinated before being infected and will be particularly important for prevention of other HPV-related cancers, such as oropharyngeal cancers, which seem to have an altogether different age-profile. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Abstract A15: Development of a multilevel human papillomavirus (HPV) vaccine intervention

Abstract Purpose: New strategies to improve human papillomavirus (HPV) vaccine uptake among minority and underserved adolescents are needed. The purpose of this study is to describe the development of a multi-level HPV vaccine intervention to increase adolescent HPV vaccination rates. Methods: A community-engaged process was used over a one year period. Caregivers (n=18) and providers (n=27) from a Federally Qualified Health Center participated in: 1) focus groups to better understand knowledge and acceptability of the HPV vaccine, and to generate ideas for the intervention content and format; 2) writing sessions to develop the content and intervention components; and 3) review sessions to obtain initial feedback and make revisions prior to pilot testing the intervention. Results: Intervention components developed were based on the Protection Motivation Theory and the PACE (Present the issue, Ask questions, Check understanding, and Express concerns) communication system. The intervention components developed (English and Spanish) focus on three levels: 1) Caregivers: a) an interactive computer program tailored for the adolescent's gender, age, race/ethnicity, b) a brochure with information about additional resources, and c) a HPV vaccine comic book to assist caregivers with explaining the HPV vaccine to younger adolescents; 2) Providers: a) an automated PowerPoint presentations including current HPV vaccine initiation and completion rates, suggestions to address common barriers, and video clips demonstrating the teach-back methodology, b) current HPV vaccine scientific literature, and c) “Ask me about the HPV vaccine!” pins; and 3) Health Centers: a) posters, and b) refrigerator magnets that serve as reminders for the second and third dose of the HPV vaccine. Conclusions: Community members provided valuable input into the development of a multi-level HPV vaccine intervention. The input will make the intervention relatable and more acceptable to the priority population. Using this community-engaged approach is more complex, increases costs, and involves additional time and effort from community members and academic researchers. The value of the partnership is critical and the additional time and energy expended is important to successfully address cancer disparities among minority and underserved populations. Citation Format: Mira Lynn Katz, Paul L. Reiter, Mack T. Ruffin, IV, Electra D. Paskett. Development of a multilevel human papillomavirus (HPV) vaccine intervention. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A15.

Factors Associated with Increased HPV Vaccine Use in Rural-Frontier U.S. States.

This study sought to examine sociodemographic factors surrounding human papillomavirus (HPV) vaccine initiation and three-dose completion rates in the Intermountain West (IW). Analysis of the Centers for Disease Control and Prevention's 2012 National Immunization Survey-Teen dataset was conducted with a survey-weighted Pearson chi-square test and multivariable Poisson regression to produce bivariate and multivariate analyses. Participants with daughters aged 13-17 with provider-verified immunization records were included. Dual-frame adjusted prevalence ratios (PR) and 95% confidence intervals (CI) were produced with provider-phase sampling weights. Factors included parents' and adolescents' sociodemographic and healthcare usage variables. Outcome measures included adolescents' receipt and completion of the HPV vaccine. Older parental ages (45years and above) showed lower prevalence of adolescent HPV vaccine initiation (PR=0.73, 95% CI=0.59-0.87, p=.003) and completion (PR=0.65, 95% CI=0.44-0.96, p=.031) compared with parents younger than 35. Seventeen-year-old adolescents demonstrated highest prevalence of initiating (PR=1.88, 95% CI=1.47-2.39, p<.001) and completing (PR=2.92, 95% CI=1.97-4.33, p<.001) the vaccination series compared to 13-year olds. Those who had received meningitis vaccinations had high prevalence of initiating (PR=1.93, 95% CI=1.50-2.48, p<.001) and completing the HPV vaccine (PR=2.52, 95% CI=1.64-3.86, p<.001). This study highlights parental, adolescent, and health care characteristics related to use of the HPV vaccine. Future research to investigate specific barriers and strategies for addressing HPV vaccination use in the IW is recommended.